118.3 🩺 內科專科考前版

118.3.0.1 📌 一頁重點

  • 22E 重大進展:
    • Pathogen reduction (INTERCEPT) 在 PC 與 plasma 普及 → 取代部分 bacterial culture，↓ 病毒/寄生蟲 risk
    • Cold-stored platelets (4°C): 較長保存（最多 21 天）+ 更佳 hemostatic capacity，trauma + cardiac surgery 應用增加
    • Whole blood transfusion 重新興起（trauma + 軍事醫療）：1:1:1 ratio in package；研究顯示部分 trauma cohort outcome 較好
    • Anti-CD38 (daratumumab) 干擾 indirect Coombs / type-and-screen → DTT-treated test cells / 預先 phenotype before therapy
    • Genotype-based RBC matching：multitransfused 病人（thalassemia, sickle cell）採用基因型 matching → ↓ alloimmunization
    • Patient blood management (PBM) 全球推廣：pre-op IV iron + EPO + cell salvage + restrictive transfusion → 減少 50% RBC use
    • Tranexamic acid (TXA) 在 trauma (CRASH-2)、產科 PPH (WOMAN)、surgical bleeding 廣泛應用
    • Convalescent plasma for COVID-19：高效 Ab donor titer 可 marginal benefit in immunocompromised (ResILIeNT trial)
  • Taiwan: 健保血品全覆蓋；輸血醫學會推 PBM；anti-D Ig (RhoGAM) 健保 indication；rare blood group programs 在血液基金會（北中南三大血庫）

118.3.0.2 🌟 Pearls (12)

  1. TRALI 機制: Donor anti-HLA class II (HLA-DR) 或 anti-HNA-3a / 5a 與受者 neutrophil binding → 肺血管 endothelium injury + capillary leak；多 multiparous female donor（懷孕 sensitization）
  2. TRALI 預防: Male-only plasma + LR + HLA Ab screening of female donors → 美國 / 歐洲 incidence 大幅 ↓
  3. TACO incidence: 1–8% of transfusions (vs TRALI 0.04–0.1%)；最常見 fatal cause of transfusion in US 自 2010s
  4. Daratumumab interference workaround: DTT-treated screening cells; phenotype RBC + Kell-typing 前 anti-CD38 啟動；some hospitals use anti-soluble CD38 reagent
  5. Whole blood vs 1:1:1 components: WB 提供同步 RBC + plasma + platelets + clot factors；存儲 21 d 仍 hemostatic；trauma trials 進行中
  6. Cold-stored platelets: 不像 RT-stored 7-day expiry，可 14-21 day；hemostatic 反而較佳（functional 而非 hibernating）；FDA approval for trauma
  7. Convalescent plasma in COVID-19: 早期 trials negative；ResILIeNT 在 immunocompromised early treatment 顯示 marginal benefit；目前限制使用
  8. Genotype-based matching for SCD: 加 Rh variants + Fy/Jk/MNS + Lewis → ↓ alloimmunization rate from 30% to < 5%
  9. TA-GVHD pathogenesis: Donor lymphocytes engraft → attack host → BM aplasia + 多器官 → 95% fatal；prevention only via irradiation
  10. HIT (Heparin-Induced Thrombocytopenia) 病人 PC contraindication: 給 platelet 加重 thrombosis（heparin-PF4 immune complex）
  11. Convalescent for emerging pathogens (Ebola, Lassa, MERS, COVID-19): pathogen-specific Ab；timing critical (early > late)
  12. Iron overload management: Deferasirox PO daily (kidney 監測); Deferoxamine SC infusion (老 standard); Deferiprone PO (myelosuppression risk); 目標 ferritin < 1000

118.3.0.3 📍 Taiwan + 健保

118.3.0.3.1 血品供應
  • 台灣血液基金會（TCBF）：北中南三血庫
  • 健保全覆蓋 RBCC, PC, plasma, cryo, granulocyte
  • Apheresis platelet (single donor) > pooled — 較少 alloimmunization 風險
  • 健保 leuko-reduced 為標準
  • Pathogen reduction 部分 medical center 已實施（特別 PC, FFP）
118.3.0.3.2 重要規範
  • 健保：D-negative RBCC for D-negative recipient（特別 childbearing potential 女）
  • 健保：Anti-D immune globulin (RhoGAM) for D-negative pregnancy at 28 wk + post-partum
  • 健保：Irradiation 適應症 — HSCT, congenital immunodeficiency, IUT, premature, fludarabine 用藥
  • 健保：Plasma exchange (TPE) for TTP, GBS, MG crisis, anti-NMDA encephalitis
  • 健保條件：rare blood group program
118.3.0.3.3 在地分布
  • D-negative prevalence：亞洲 < 1%（vs Caucasian 15%）→ 較少 anti-D 議題但 D-negative 病人血源稀缺
  • Bombay phenotype: 印度後裔（rare in Taiwan）
  • Thalassemia 高 prevalence: 多次輸血 → genotype matching + iron chelation 重要
  • Hemoglobinopathy 健保: 規律輸血 + chelation + HSCT 條件給付
  • 學會：台灣輸血學會 + 台灣血液基金會 共識
118.3.0.3.4 病人衛教
  • 輸血同意書 + 副作用解說
  • 多次輸血 / 規律輸血 → 鐵負荷 + chelation 教育
  • D-negative 女性 + 兒童特別注意 K + RH compat

118.3.0.4 🎓 內專必懂 (12)

  1. WHO + ISBT blood group classification + 45 systems + 390 antigens
  2. TRALI: 機制 + male-only plasma policy + HLA Ab donor screening
  3. TACO: incidence 高於 TRALI + BNP-guided 鑑別 + 預防 (slow rate, diuretic)
  4. TA-GVHD: 機制 + irradiation indication + 親屬輸血 警告
  5. MTP / PROPPR: 1:1:1 + TXA + cryo + calcium + temperature
  6. PBM 三柱: hematopoiesis + minimize loss + tolerance
  7. Pathogen reduction (INTERCEPT): 機制 + 取代 bacterial culture
  8. Cold-stored platelets: 22E 趨勢 + trauma application
  9. Whole blood: 重新興起 + 軍醫應用
  10. Daratumumab interference + DTT workaround
  11. Genotype-based matching for hemoglobinopathy
  12. Convalescent plasma: emerging pathogens + COVID-19 lessons

118.3.0.5 🔬 進階機轉

118.3.0.5.1 TRALI Two-Hit Hypothesis
  • Hit 1 (priming): 受者本身 inflammation (sepsis, surgery, ECMO) → neutrophil sequestration in lung
  • Hit 2 (activation): Donor anti-HLA/HNA → neutrophil 釋放 free radicals + proteases → endothelial injury + capillary leak
  • 多 multiparous female donor（懷孕 sensitization → anti-HLA）→ male-only plasma 政策
118.3.0.5.2 Storage Lesion
  • RBC 隨儲存時間 ↑ K leak + 2,3-DPG ↓ + ATP ↓ + microparticles ↑ + free hemoglobin ↑
  • Clinical impact controversial（多 RCT 顯示 fresh vs old similar outcome）
  • Massive transfusion 中 fresher RBC 可能 preferred
118.3.0.5.3 Pathogen Reduction Technologies
  • INTERCEPT (amotosalen + UVA): amotosalen 嵌入 nucleic acid → UVA 照射 → cross-link → 不可複製
  • Mirasol (riboflavin + UV)
  • THERAFLEX-UV-Platelets
  • 對 RNA + DNA viruses + bacteria + parasites 有效；不對 prion / non-enveloped 抗藥
118.3.0.5.4 Whole Blood vs 1:1:1
  • WB: 50% Hct, ≥ 175 mL plasma, ≥ 60K platelets/mL → balanced resuscitation
  • 軍事醫療多年使用；civilian trauma 試驗增加（PROCOAG, PROPPR-WB）
  • 限制：cross-match + storage（4°C × 21 day）

118.3.0.6 ⚠️ 內專易錯點

  • TRALI 給利尿 → 加重 hypoperfusion
  • TACO 不警覺 BNP → 漏診
  • TA-GVHD 風險病人不 irradiate → 95% 致死
  • 親屬輸血未 irradiate → 高風險 TA-GVHD
  • Daratumumab pre-treatment 不 phenotype → 之後 type-and-screen 困難
  • Multitransfused thalassemia 病人 not genotype matching → alloimmunization 累積
  • MTP 不 1:1:1 ratio → 凝血病
  • Hyperkalemia 大量輸血不監測 → arrhythmia
  • Iron overload 不 chelation → cardiac / endocrine / liver damage
  • HIT 病人給 PC → 加重 thrombosis（contraindicated 除非 life-threatening bleed）
  • Pre-op IDA 直接輸血而非 IV iron → 不必要輸血
  • D-negative 女童輸 D-positive without anti-D Ig follow-up

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